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Answer from Coach Barken, Israel Barken, M.D to question 1:
Yes, it is safe to be on hormonal blockade prior to
radiation. A recent study showed that continuing hormonal blockade for 6 months is significant in terms of efficacy. |
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Answer from Coach Barken, Israel Barken, M.D to question 2:
It is customary to shrink the tumor if radiation seeds
or cryosurgery are planned. Some times it is done just to gain some time until the patient can make his own decision.
Most urologists do not recommend hormonal blokcade prior to radical prostatectomy because they claim it is more difficult to save the nerves for erection.
Dr. Soloway from Florida used to operate on patients I referred to him and he did not mind the hormonal blockade prior to surgery.
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Answer from Coach Barken, Israel Barken, M.D to question 3:
The standard in this country is avoiding surgery if there is a chance that the disease is not localized. Many patients undergo hormonal blockade followed by radiation and hormonal blockade after that. The classical study by Bola used 3 years of hormonal blockade after radiation . The recent article by Dr. D'Amico in JAMA 2004, vol 292: 821-827 advocates only 6 months after radiation.
Dr. Mack Roach's approach is defined according to RTOG 9413. The study showed that the group that got 2 months of hormonal blockade prior to the radiation and 2 months during the whole pelvic radiation therapy had the best outcomes.
I personally think that Laparoscopic surgery after pelvic lymph node dissection is a good way to maximize the efficacy of treatment in young men. Cryosurgery can also be done in patients who don't feel comfortable with surgery. I am a bit biased against radiation. Many of the centers admit that only hormonal blockade and radiation are not enough and that there is a need to study combining radiation and hormonal blockade with additional chemotherapy. I think cryosurgery can be combined with chemotherapy also.
If the patient plans on radiation, it makes sense to do a Spectroscopic MRI to be able to follow up on the effect of the radiation on the prostate gland.
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Answer from Coach Barken, Israel Barken, M.D to question 4:
I think that the best chance of cure is for patient to combine different treatments. I don't think that not achieving cure means that the patient will necessarily get into trouble. I believe in combining many treatments and controlling the disease without causing side effects that will affect the quality of life. My approach is to
balance "Minimum Intervention treatments with Maximum Surveillance" using imaging tests and follow up with molecular tumor markers.
I don't think that it is possible to just match his situation to studies to find the best treatment. We need to take into account his attitudes, his personality and his life experiences as well as his specific medical situation and then find what treatment approach is "right" for him.
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Answer from Dr. Strum, M.D:
What would make more sense is:
1) Check the PSA each month on ADT to see if it drops to < 0.5 (prognostic purposes) and with additional therapy to < 0.05 (therapeutic and prognostic purposes)
2) See if the PSA drops to < 0.05 using an ultra-sensitive PSA since this will tell us the probability of Androgen Dependent PC (ADPC) versus Androgen Independent PC (AIPC). This is discussed in our book called "A Primer on Prostate Cancer, The Empowered Patient's Guide" by Strum & Pogliano.
3) Measure testosterone levels each month to be sure they are < 20ng/dl or the equivalent to this.
4) Measure fasting AM prolactin level since prolactin influences testosterone effect on PC growth.
5) Obtain levels of other biomarkers such as PAP (Prostatic Acid Phosphatase), CGA (Chromogranin A), NSE (Neuron Specific Enolase) and CEA (Carcino-Embryonic Antigen) since high Gleason score PC often expresses these markers and reliance on PSA only can be very misleading. This is discussed on page 64 of "A Primer on Prostate Cancer, The Empowered Patient's Guide".
6) Obtain a QCT(Quantitative Computerized Tomography) BMD (bone mineral density) since the bone environment has huge effects on PC growth. |
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Answer from Dr. Strum, M.D to question 1:
Part of the safety is dependent on the suggestions made above. If all markers of PC activity are continuing to drop, then continued ADT(androgen deprivation therapy) is more helpful to your father's outcome than is the focusing on local or regional therapy. The "enemy" is not just local, but systemic. Surgery is not really indicated in your father's case unless
there are special circumstances such as severe urinary problems with emptying the bladder. Otherwise, surgery limits the extent of tumor cell kill to the surgical field.
At least RT goes beyond that pending the skill and the equipment available for the RT.
There should be at least 3D Conformal RT available if not IMRT (Intensity Modulated Radiation Therapy). However, this therapy and other therapies relying on direction of energy to the tumor to kill cells does RELY HEAVILY on the tumor target being reduced sufficiently for the RT to be able to kill all the cells. Larger tumors have centers where the oxygen tension is relatively low. These hypoxic centers are radiation resistant. If your father is treated with RT prematurely, when the tumor burden has not been reduced significantly, he will experience a greater chance of local disease persistence after RT. |
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Answer from Dr. Strum, M.D to question 2:
Yes. Especially RT or cryosurgery or HIFU. In your father's case, I would prefer he be on Flutamide or Casodex along with Proscar or Avodart. |
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Answer from Dr. Strum, M.D to question 3:
In summary, better staging, use of more
comprehensive ADT involving 3 or more agents, use of BIOLOGIC ENDPOINTS to tell me that my job is being accomplished. These end points have been
discussed above, e.g. PSA < 0.05, normalization of DRE, normalization of endorectal MRI, etc. |
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Answer from Dr. Strum, M.D to question 4:
Putting all of these measures together in an integrative fashion which also involves approaches that deal with nutrition, anti-oxidants, high-tech studies, coupled with outstanding physicians with expertise in all aspects
of this illness. My best wishes for your father's successful treatment outcome. |
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